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Management of Buried Bumper
Syndrome
By Dr Kalsom Abdulah
28.5.2014
Percutaneous Endoscopic Gastrostomy
(PEG)

Percutaneous endoscopic gastrostomy (PEG) was first reported in the
literature...
PEG tube placement
Indications & contraindications for PEG
tube
Indications
• Neurological event: CVA, PD, ALS, MS, HIV encephalopathy, traum...
Acute Buried Bumper Syndrome

BBS is uncommon complication of PEG tube placement

Occurs when the internal bumper of a P...
Risk factors for BBS
• Obesity
• Rapid weight gain, in particular if loosening of the external bumper
is not also attended...
Signs & Symptoms of BBS

Clogging and immobilization of the tube

Abdominal pain

Inability to infuse feedings

Peritu...
Complications of BBS

Perforation of stomach

Peritonitis

Death
Possible Considerations in Preventing
Buried Bumper Syndrome
• Allow an additional 1.5–2 cm between the external bumper an...
Treatment of BBS

Removal of buried bumper (even if asymptomatic)

PEG removal using external traction

Incision & drai...
Conclusion

BBS is an unusual late complication of percutaneous endoscopic
gastrostomy tube placement

Is not a benign p...
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Buried bumper syndrome

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PEG tubes are becoming increasingly in demand for alternative enteral feeding options. Thus, BBS is a common complication that one should be aware of and how to manage it. Hope this helps..

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Buried bumper syndrome

  1. 1. Management of Buried Bumper Syndrome By Dr Kalsom Abdulah 28.5.2014
  2. 2. Percutaneous Endoscopic Gastrostomy (PEG)  Percutaneous endoscopic gastrostomy (PEG) was first reported in the literature in 1980 as an alternative way to provide tube feeding for patients without a laparotomy  Today, PEG placement is widely accepted as a safe technique to provide long-term enteral nutrition for a variety of patients including those with neurologic deficits and swallowing disorders and those with oropharyngeal or esophageal tumors and various hypercatabolic states like burns, short bowel syndrome, and major traumas  Although considered a safe procedure, immediate and delayed complications have been described with the PEG placement. These complications vary from minor complications like wound infections to major life threatening complications like peritonitis and buried bumper syndrome.  BBS is an uncommon but serious complication of PEG, occurring in 0.3– 2–4% of patients.
  3. 3. PEG tube placement
  4. 4. Indications & contraindications for PEG tube Indications • Neurological event: CVA, PD, ALS, MS, HIV encephalopathy, trauma, dementia, brain tumour • Anatomic: tracheoesophageal fistula • Malignant obstruction: oropharyngeal or oesophageal masses • Other: gastric decompression, burn patients, severe bowel motility disorder Relative Contraindications • Peritoneal metastases • Peritoneal dialysis • Ascites • Coagulopathy • Poor life expectancy • Acute illness (respiratory distress) • Severe obesity • Open abdominal wound • Ventral hernia • Portal hypertension with gastric varices • Sepsis CVA – cerebrovascular accident; PD – Parkinson’s disease; ALS – Amyotrophic Lateral Sclerosis; MS – Multiple Sclerosis
  5. 5. Acute Buried Bumper Syndrome  BBS is uncommon complication of PEG tube placement  Occurs when the internal bumper of a PEG tube erodes and migrates throught the gastric wall and becomes lodged anywhere between the gastric wall and the skin  If not removed and treated appropriately, can lead to life- threatening complications  Incidence rate is 1.5-2.4% and can occur from days to years post PEG placement
  6. 6. Risk factors for BBS • Obesity • Rapid weight gain, in particular if loosening of the external bumper is not also attended to • Patient manipulation and pulling of the PEG • Placement of multiple gauze pads or other coverings beneath the external bumper • Repositioning of the external bumper by inexperienced personnel • Chronic/severe cough • Frequent or inadvertent tube traction by caregivers
  7. 7. Signs & Symptoms of BBS  Clogging and immobilization of the tube  Abdominal pain  Inability to infuse feedings  Peritubular leakage  Ability to palpate internal bumper clinically  Endoscopic evidence  CT showing migrated internal bumper
  8. 8. Complications of BBS  Perforation of stomach  Peritonitis  Death
  9. 9. Possible Considerations in Preventing Buried Bumper Syndrome • Allow an additional 1.5–2 cm between the external bumper and the skin. • Visualize the internal bumper (immediately following the PEG placement) to confirm its location prior to applying the external bumper • Once a day gently rotate and push the PEG in and out ~1–2 cm • Display simple diagrams of the PEG system at the bedside in the hospital or clinic. • Length of the protruding external portion of the PEG should be measured periodically to recognize early migration
  10. 10. Treatment of BBS  Removal of buried bumper (even if asymptomatic)  PEG removal using external traction  Incision & drainage if abdominal wall abscess present  Endoscopy − To determine the exact condition of the site − Whether same site can be used for replacement PEG − Plan the direction of PEG removal  Replacement tube through same site if healed previous abscess  Administer antibiotics  Wound care
  11. 11. Conclusion  BBS is an unusual late complication of percutaneous endoscopic gastrostomy tube placement  Is not a benign problem and can lead to life threatening complications  Treatment usually involves removal of the tube along with wound care  Although several factors can contribute to the development of disorder, can be prevented with proper patient care and education for the caregiver and patient

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